Practical Bioethics

A blog of the
Center for Practical Bioethics

Thursday, April 28, 2016

This Is How Prince’s Death Begins Conversation About Addiction

Myra Christopher

INTRODUCTORY NOTE FROM MYRA CHRISTOPHER

Lynn Webster, author of the blog below, is a member of Pain Action Alliance to Implement a National Strategy (PAINS) Steering Committee. He is also one of the most authoritative and committed experts in the United States working on both pain and addition. PAINS has been benefitted tremendously from his involvement in our efforts to “transform the way pain is perceived, judged and treated.”

Over the last couple of years, PAINS has come to understand the importance of embracing the need for dramatic change in the way two diseases – chronic pain and substance abuse disorders, especially opioid addiction -- are addressed, and that by advocates focused on both working together, we are far more likely to improve the health and well-being of all Americans.

Although relationship the between these two public issues is not yet clearly understood, there is without question a correlation between the two. Unfortunately, these two patient populations have often been pitted against one another by the media and fear-mongers for personal or political advantage. PAINS has attempted to reach out to those focused on opioid addiction and to neutralize some of the ill-will between those focused on pain and those focused on addiction.

These efforts are gaining some traction with people of goodwill – no matter their primary locus of concern; PAINS is committed to this work because we are confident that there are shared values and common ground upon which we can collaborate.

We are grateful to Dr. Webster for allowing us to post a blog he wrote shortly after the sudden death of one of America’s great artists, Prince. We believe it makes a compelling case for what PAINS is trying to do.

I still don’t have all the facts about the circumstances surrounding Prince’s death. I wasn’t Prince’s physician during his lifetime, and I had no opportunity to look at his medical records either before, or after, his death.

All I know about Prince’s death is what you know. Some entertainment media outlets (TMZ, Variety, and more) initially reported that Prince was treated with naloxone, which is the antidote for opioids including heroin, in the days before his death. An autopsy (in which I had no participation) was conducted on Prince’s remains, and according to CNN, it could be weeks before we know why the beloved musical icon is no longer with us.

Several of my colleagues and friends posted a link to my blog on their social networks, and they told me they were surprised to see that some of their supporters had reacted swiftly and furiously. For example, Jan Favero Chambers, President/Founder of the National Fibromyalgia & Chronic Pain Association, was gracious enough to post a link to my blog on her Facebook page.

Among the negative comments she shared with me was this one:

“Jumping the gun a bit. We don’t know the cause of death. Respect his memory, by not posting this.”

If you look at the comments below my original blog, you’ll find someone raised an objection there, too:

“Why are you using Prince to draw people into this article? Do you know his medical history? Have the autopsy results come back? Please school me on your knowledge,” reads the comment.

Empathize, Don’t Blame, People in Pain or With Addiction

As I said in my response to that comment, part of my life’s work is to teach people to empathize with, and not blame, people in pain or with addiction. The untimely death of a beloved musical icon provides an opportunity to test our ability to demonstrate compassion. That is why I blogged about it.

I blogged about the death of Prince not because I jumped to conclusions about how he died. As I wrote then, I didn’t know any more about the cause, or causes, of his death than anyone else who hadn’t treated him or viewed his medical records.

But what I did know is that we, as members of society, had experienced a communal loss. While that’s tragic and sad, it provides us with one benefit: an opportunity to compassionately discuss the difficult topic of addiction and related issues.

Since TMZ, Variety, and other entertainment media had linked Prince’s death with naloxone, which is the antidote for opioids including heroin, I believed (and I still believe) that it was a good time to discuss addiction.

Addiction Is a Disease, Not a Character Flaw

Addiction is a disease, and yet it frequently elicits anger and judgment rather sympathy and support. This is true for everyone, famous or not, with addiction.

I don’t know whether Prince was one of the people with addiction. But what I do know is that, as an addiction specialist, I treated thousands of people with addiction over the years. My professional background qualifies me to make the observation that it’s wrong to deny compassion to the people in various stages of the disease of addiction.

When we blame people with addictions for the choices that led to their addictions, we overlook the fact that addiction is a complex problem. Because there are so many factors involved in addiction, it’s inaccurate and unfair to point a finger at an individual and say, “This disease is your fault.”

It is true that we all own some agency for our decisions, but once the disease of addiction is firmly rooted, the power to choose is stolen by the brain.

My concern was that, if the medical evidence supported the conclusion that Prince died of addiction, the outpouring of devotion that his memory had inspired would turn to rage against him. That, in my opinion, would be a shame, because the people we care about — whether they are family members, friends, colleagues, or celebrities whom we’re unlikely to meet in person — are as worthy of our love in their sickness as they are when they enjoy their full health.

To me, the death of Prince represents an opportunity to begin a discussion about why we negatively judge anyone who is sick. It provides us all with an opportunity to open up our hearts and listen to people in pain and with addiction.

And, most of all, it gives us a chance to feel compassion toward all people, sick or healthy, famous or anonymous, rich or destitute, gifted performer or shy wallflower, and friend or stranger. We’re all members of the same tribe, the human race, and we’re all entitled to love and understanding during every stage of our lives — whether we make good choices or bad choices, and whether we enjoy the happiness of success and health or the difficulties of sickness and even death.

Thursday, April 21, 2016

New Reasons for Outrage Over Persistence of Healthcare Disparities: Ignorance and Neglect

Richard Payne, MD

Race and socio-economic status are regrettably important
factors in determining life expectancy. There has been a persistent gap in
mortality between whites and blacks for many decades, with one study showing
that blacks suffer approximately 800,000 “excessive deaths” over a 10-year
period relative to whites. More recently, studies have demonstrated that the
wealthiest Americans live more than 8 years longer than less wealthy Americans and,
tragically, color is still a marker for poverty in our country.

Although various studies indicate that lower socio-economic
status is the most powerful determinant of health, there have been a plethora of
studies over the past two decades showing that there are disparities in access
and outcomes of care between whites and communities of color, especially black
and brown. Tellingly, these disparities even occur in the Medicare system,
where there is a presumption of equal access.

Black and White Pain

Now, a recent spate of articles adds THREE more factors
responsible for persistence of healthcare disparities: ignorance, neglect, and
lack of conviction to change the status quo. Earlier this month the National
Academy of Sciences published the results of a University of Virginia study in
which 222 white medical students and residents were asked to rate on a scale of
zero to 10 pain levels they would associate with two mock pain cases – for both
a white and black patient. It was not surprising that the students rated pain
lower for black patients than whites and chose less aggressive treatment
options for people of color, because disparities in pain assessment and
treatment have been reported for decades. The students were simply reflecting
this unfortunate reality.

More disturbing were the reasons underlying the students’ choices.
For example, 8% and 14% of first- and second-year medical students,
respectively, endorsed the belief that “blacks’ nerve endings are less
sensitive than whites’” and 29% of first-year and 17% of second-year medical
students endorsed the belief that “black people’s blood coagulates more quickly
than whites’.” On average, about 50% of participants reported that at least one
of the false belief items as probably or definitely true.

These and other responses reflect frankly racist myths and
misconceptions and conform to stereotypes that many of us had hoped were long
ago vanquished. Of great importance, the study also found that “racial bias in
pain perception is associated with racial bias in pain treatment
recommendations.”

Explaining the Bias

Myra Christopher

This level of biological ignorance among medical personnel
is, as the authors of the study said, “highly surprising.” We would add that it
is unacceptable and outrageous. But how does one explain this level of
ignorance in otherwise highly intelligent and educated medical students? One
can only assume that these data would be similar in other medical schools,
although this needs further study. One can speculate that some of this
ignorance is related to implicit racially-based biases (which by definition
operate at a subconscious level) that all persons exhibit, even doctors.

There are likely many reasons other than poor medical school
pedagogy for this ignorance. According to 2013-2016 American Association of
Medical College Statistics, only 7.8% of applicants to U.S. medical schools are
African-Americans (compared to 48% whites and 19.3% Asian). Although we do not
have data on the racial demographics of the University of Virginia medical
school class, one can only wonder if racial and socio-economic factors among
the respondents in the study were such that they had little exposure to blacks.
This would not be surprising. Many commentators have reported that one of the
reasons for persistence of the racial divide in the U.S. is that we are, as the
award-winning author David Shipler described in the title of his book, A Country of Strangers. The relatively
affluent and privileged applicants that apply to medical school and eventually
become doctors likely grow up with little exposure to African-Americans.

Bioethics Response?

It is important to see how we in the bioethics community
respond to the University of Virginia and similar studies. Recently, a spate of
articles criticizing the relative lack of commentary and activity related to
the negative effects of racism in medicine have appeared in the bioethics
literature. The April issue of the American
Journal of Bioethics focused on this problem. Pointing to a paucity of
articles and analysis of the impact of racism on the persistence of health
disparities, and the failure of bioethicists to address this issues over time,
John Hoberman claims in a recent Hastings
Report article that the field of bioethics has a “race problem” and that the
“ moral imagination in bioethics has largely failed African-Americans.” The
neglect of targeting the obvious injustice of persistence of racially-based
health disparities by the sharp analytical and philosophical minds in bioethics
is an outrage and must be remedied.

All of us who analyze or deliver healthcare or who create
policy to regulate and administer it are obligated to respond to injustice. Not
to do so is an outrage. Thomas Jefferson once said: “Do you want to know who
you are? Don’t ask. Act! Action will delineate and define you.” These are wise
words indeed. Put another way, the persistence of inaction will condemn us as
moral failures.

Richard Payne, MD, holds
the John B. Francis Chair at the Center for Practical Bioethics and the Esther
Colliflower Professor of Medicine and Divinity at Duke Divinity School, Duke
University.

Myra Christopher holds
the Kathleen B. Foley Chair in Pain and Palliative Care at the Center for
Practical Bioethics.

About Me

The Center for Practical Bioethics is a nonprofit, free-standing and independent organization nationally recognized for its work in practical bioethics. Since 1984, the Center has helped patients and their families, healthcare professionals, policymakers and corporate leaders grapple with ethically complex issues in medicine and research.
For more go to www.practicalbioethics.org.
The editor of this blog is John Carney at the Center. For questions or suggestions, email jcarney@practicalbioethics.org.